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Which of the following would most immediately threaten an individual's safety? Lack of water 70% humidity A sprained ankle Unrefrigerated fresh vegetables - ✔✔a. Lack of Water The developmental stage that carries the highest risk of an injury from a fall is: Adulthood School age Older Adulthood Preschool - ✔✔Older Adulthood Mrs. Field falls asleep while smoking in bed and drops the burning cigarette on her blanket. When she awakens, her bed is on fire, and she quickly calls the nurse. On observing the fire, the nurse should immediately: Report the fire Assist Mrs. Field to a safe place Attempt to extinguish the fire Close all windows and doors to contain the fire - ✔✔Assist Mrs. Field to a safe place
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Which of the following would most immediately threaten an individual's safety? Lack of water 70% humidity A sprained ankle Unrefrigerated fresh vegetables - ✔✔a. Lack of Water The developmental stage that carries the highest risk of an injury from a fall is: Adulthood School age Older Adulthood Preschool - ✔✔Older Adulthood Mrs. Field falls asleep while smoking in bed and drops the burning cigarette on her blanket. When she awakens, her bed is on fire, and she quickly calls the nurse. On observing the fire, the nurse should immediately: Report the fire Assist Mrs. Field to a safe place Attempt to extinguish the fire Close all windows and doors to contain the fire - ✔✔Assist Mrs. Field to a safe place A man who is caring for his aging parents is concerned about factors that put them at risk for falls. Which are most likely to contribute to an increase risk for falls in the elderly? (Select all that apply.) Inadequate lighting
Staircases with handrails Throw rugs Multiple medications Cords covered by carpets - ✔✔Inadequate Lighting Throw Rugs Multiple Medications Cords Covered by Carpets At 3 pm, the Emergency department nurse hears that an explosion has occurred at the local milk plant. Which action does the nurse take first? Contact the American Red Cross Determine how to resume normal operations Evacuate patients per the disaster plan Prepare for an influx of patients - ✔✔Prepare for an Influx of Patients Mr. Green, a 62-year-old farmer, has been hospitalized for 2 weeks for thrombophlebitis. He has no visitors, and the nurse notices that he appears bored, restless, and anxious. The type of alteration occurring because of sensory deprivation is: Cognitive Affective Receptual Perceptual - ✔✔Affective Which of the following would not provide meaningful stimuli for a patient? Interesting magazines and books A clock or a calendar with large numbers Family pictures and personal possessions
A television kept on all day at low volume - ✔✔A television kept on all day at low volume Patients with existing sensory loss must be protected from injury. What determines the safety precautions taken? The existing dangers in the environment The financial means to make needed safety changes The nature of the patient's actual or potential sensory loss The availability of a support system to enable the patient to exist in his or her present environment - ✔✔The nature of the patient's actual or potential sensory loss A patient who is unable to name common objects or express simple ideas in writing or words has: Global aphasia Receptive aphasia Mental retardation Expressive aphasia - ✔✔Expressive Aphasia Mrs. DeLone states he is worried about his parents' plans to retire. All of the following would be appropriate responses regarding retirement of older adults except: Retirement may affect an individual's physical and psychological functioning Positive adjustment is often related to how much a person planned for the retirement Reactions to retirement are influenced by the importance that has been attached to the work role Retirement for most persons represents a sudden shock that is irreversibly damaging to self-image and self-esteem - ✔✔Retirement for most persons represents a sudden shock that is irreversibly damaging to self-image and self-esteem. Mr. Brown is having some difficulty breathing. The nurse most appropriately assists him into the:
Fowler's position lateral position dorsal recumbent Sims' position - ✔✔Fowler's Position Mrs. Eden tells the nurse that she feels faint and unsteady while walking in the corridor with the nurse. The nurse: Advises her to look down at her feet to help maintain her balance Provide a wide base of support with one foot in front of the other, and ease her to the floor Leaves her momentarily to find another nurse for help Instructs the patient to quicken her pace so they can return to her room - ✔✔Provide a wide base of support with one food in front of the other, and ease her to the floor The expected result more protein is being broken down than is manufactured, secondary to immobility, is: Fluid volume excess Osteoporosis Negative nitrogen balance Muscle hypertrophy - ✔✔Negative Nitrogen Balance A bedridden patient who is blind is admitted to a healthcare facility with pressure ulcers on the sacral area. A priority nursing diagnosis is: Risk for altered body temperature related to stage 2 pressure ulcer Feeding self-care deficit related to blindness Impaired skin integrity related to immobility Activity intolerance related to prolonged bed rest - ✔✔Impaired skin integrity r/t immobility
While performing range-of-motion exercises with a bedridden patient, the nurse is aware that: Neck hyperexetension should be encouraged, particularly in older people Exercises should be continued until the patient is fatigued Exercises should be done frequently to lessen pain for the patient Each joint should be exercised to the point of resistance, but not pain - ✔✔Each joint should be exercised to the point of resistance, but not pain Which of the following is an appropriate intervention when using antiembolism stockings? Start application by scrunching the hose down to within an inch from the toe area and sliding it over the toes Remove stockings at least once per shift to inspect the skin Roll the top of stocking down a few inches for patient comfort Patients should be encouraged to routinely massage legs to stimulate blood flow - ✔✔Remove stockings at lease once per shift to inspect skin Which of the following is a consequence of immobility? Increased bone density Increased bladder emptying Atelectasis Muscle hypertrophy - ✔✔Atelectasis Which of the following is an appropriate way to care for an unconscious patient? Place the patient in the supine position for oral care Use a cup to pour liquids into their mouth to rinse toothpaste during oral care Explain procedures to the patient before performing them
Do not speak when in the room to avoid sensory overload - ✔✔Explain procedures to the patient before performing them The effects of immobility on the cardiac system include which of the following? (Select all the apply) Orthostatic hypotension Increased cardiac workload Thrombus formation Irregular heartbeat Weak peripheral pulse - ✔✔Orthostatic Hypotension Increased Cardiac Workload Thrombus Formation The nurse would expect all of the following physiological effects on the body with exercise, EXCEPT: Decreased cardiac output Increased respiratory rate and depth Change in metabolic rate Increased muscle tone, size and strength - ✔✔Decreased Cardiac Output Which of the following substances will promote normal sleep patterns? alcohol opioid narcotics beta-blockers tryptophan - ✔✔Tryptophan Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain secondary to arthritis. What would be the appropriate nursing diagnosis for her?
Insomnia related to chronic leg pain Deficient knowledge related to sleep hygiene measures Insomnia related to arthritis Fatigue related to leg pain - ✔✔Insomnia r/t chronic leg pain All of the following are symptoms of sleep deprivation EXCEPT: Rise in body temperature Hyperactivity Irritability Decreased motivation - ✔✔Rise in Body Temperature Which of the following is most appropriate use of good body mechanics? Focus the weight of your body on your strongest leg when lifting Bend at the waist while lifting Keep the legs straight when lifting Contract your gluteal and abdominal muscles when lifting - ✔✔Contract your gluteal and abdominal muscles when lifting A patient falls asleep in the middle of a conversation. This disorder is called? Hypersomnia Somnambulism Sleep apnea Narcolepsy - ✔✔Narcolepsy Which age group commonly requires more sleep?
Adults Older adults Adolescents Infants - ✔✔Infants Nurses spread their feed apart when they prepare to help raise a patient form a chair The most important reason for doing this is: provide a wide base of support facilitate use of the stronger back muscles make a long midriff use the patient's body weight to assist with movement - ✔✔Provide a wide base of support A patient performs sit ups. This type of exercise is referred as: aerobic isometric isotonic isokinetic - ✔✔Isometric When using a cane for support, the nurse is aware that the patient should: hold the cane on the weaker side advance the weaker foot ahead of the cane keep the elbow holding the cane stiff and straight hold the cane on the stronger side - ✔✔Hold the cane on the stronger side